 Thank you Abhishek and so this topic of MRI in ovarian mass lesion is basically something which we have been doing since long and we all understand that out of the imaging modalities which are available to us ultrasound and MRI are the modalities which we go for whenever we have pelvic lesions specifically female pelvic lesions and then to know the organ of origin and then to characterize this lesions. So the basic aim every time is to characterize them as whether they are benign or malignant and something like very similar to bi-rats which we are all accustomed with now we have o-rats and o-rats have tried to made our make our lives very simple and systematic. So the main aim of this talk will be just to go stepwise through o-rats the lexicon and how they have tried and classified to approach these ovarian masses. So this system is to ensure uniform unambiguous MRI evaluation of ovarian and adnexal lesions as well. So it is not only ovarian but adnexal. So fallopian tube etc is also included in this same o-rats lexicon. And history wise it just started somewhere in early 2015 when this entire team came in the committee was formed and 2020 they have brought in this o-rats completely with MRI lexicon as well. So if you go to their site on this acr.org they give you this kind of hyperlinks. So o-rats MRI risk stratification is there then lexicon is there and a complete white paper is there to explain everything in detail. So we will just revise this in the next 10 minutes. So there are seven criteria which you have to use to describe these ovarian lesions. If you want you can make a table of it for your reporting templates and use them. So your reports also will be very clear and quick also. So basically physiologic observation are you confident that it is a follicle or is it a corpus luteum cyst. So that has to be in a premenopausal female only that is one thing and you can just put it on paper it is a follicle corpus luteum cyst like that. Second determine whether it is non physiological. So it is either assist a lesion with solid component or a solid lesion itself. Next you have to comment on the size so as we measure on MRI routinely those dimensions margin to margin three dimensions of the lesion shape only two lexicon are there smooth or irregular. Signal intensity homogeneous or heterogeneous that is the descriptor homogeneous is same intensity all over and heterogeneous as we know it is a mixed intensity. So they have also described T2, T1 and diffusion when to call it hyper intense when to call it hyper intense. So we will see then the lesion component how much is the solid component whether to call it completely solid or solid cystic and then enhancement enhancement has to be in two ways one is dynamic enhancement one is non dynamic. So dynamic is important and then whether there are some additional findings extra variant findings or not. So basically these are the guidelines. So first if you see average risk patient with no acute symptoms. So basically you are using ORADS for these kind of patients. If there are multiple lesions each lesion will be given one ORAD and the highest ORADS will be considered for the management point of view similar to what by RADS is and then these are the main pointers they have put in separately they have put in the dermoids that the fat containing lesions can be into ORADS 2 also and can be into ORADS 4 also. So that is important to know the differentiator between the two so that we will see and dynamic contrast enhancement with perfusion are preferred over non dynamic. So all these definitions are there when to call it a simple fluid when to call it hemorrhagic fluid when to call it proteinaceous fluid all of these they have described one to all including the definition of eddexa. So I have taken few important lexicons just to discuss that cystic lesion lesion with solid component solid lesion so three terms cyst with solid component or solid lesion. Cystic lesion can be unilocular or multi-locular easy to understand lesion with solid component so that solid component can be a papillary formation like we call it like a papillary projection is present or not, neural nodule it can be irregular wall thickening or a solid portion in itself. Other solid components not considered as solid tissue so they are not solid tissue they are just solid component which is fat debris and clot or a thick wall septation so that is important if fat is present you do not call it a solid component within the lesion it is just a fat component which is seen. So not considered solid tissue this will not upgrade your ORAT score and solid lesion is consist of at least 80% of solid tumor in that particular lesion so this is the term they are using so one thing to remember is more than 80% solid is actual solid and if you have clot you are confident it is debris non enhancing clot debris or fat component you do not consider it as solid. So this is called hyperintensity so T2 is with respect to CSF for hyperintensity and with respect to your muscles like isleosource muscle for hyperintensity so observations which are hyperintense to your muscle is T2 hyperintense observation which are hyperintense to CSF or equivalent to CSF they are actual hyperintense so that means they have described every pointer which we are using in our report so everything is very clear so there is no ambiguity that whether it is hyperintense, hyperintense when to call it solid cystic again T1 wise the comparison is with fat for hyperintensity and muscle for hyperintensity. And then these are the ways they have described the lesions so whether it is just a unilocular lesion with thin wall or a unilocular lesion with multiple septae lesion with papillary projections lesion with mural nodules so the graphic representation lesion with thick septations which are enhancing lesion with more than 80% solid component and lesions which are almost completely solid. Now coming to the enhancement curve so we will see the examples but when you perform this dynamic study you all must have done it for the breast MR if you are doing it or even for prostate or even for pituitary so this dynamic MRI will be multi-phasic MRI and you have to form these curves when you post process these images. What is most important is the initial rate of uptake of contrast that is more important as compared to what happens to the curve later on. So the lesions which have a higher rate of early pickup so rapid enhancement here you can see the lesion and myometrium so two different curves the angle theta with the horizontal when it is more then that means it is a higher rate of enhancement and that makes it a higher grade or risk of malignancy goes higher up. So lesion which is just slowly enhancing as compared to a normal myometrium and not taking much of contrast is more towards benign. Lesion which is picking up contrast but still less than myometrium the rate is also less than myometrium still low grade. Lesion which is quickly picking up contrast when compared to myometrium and then plateauing almost equivalent to myometrium then it is towards a higher grade of ovarian lesion. Then we have doubt when to call it papillary projection or when to call it mural nodule therefore I have just taken this also papillary projection is enhancing solid component which is arising from the inner or outer wall or septa of an adnexal lesion with a branching architecture so mainly those papillaries should be present and nodule is a simple nodule more than 3 millimeters in size so like a solid nodule there. Then coming to how the dynamics of contrast enhancement they are changing the categories so that is why you have to use dynamic post contrast otherwise it will be difficult to assign orads 3, 4 or 5 for these lesions. So the way the tumor is enhancing if it is in the lowest curve as we discussed it becomes orads 3 so there is a solid enhancing component your cyst is a unilocular or multi locular cyst it has a solid component it has a mural nodule which is enhancing now you have to determine whether the enhancement is low risk curve intermediate or high risk curve if it is a high risk curve it is quickly picking in contrast then it becomes orads 5 directly if it is slowly taking up contrast as compared to myometrium it remains into orads 3. And associated findings peritoneal thickening peritoneal fluid again making your lesions towards malignant spectrum or higher grade spectrum so thickening whether it is smooth or not uniform or not irregular thickening is important and peritoneal fluid whether it is just physiological or if it is simple acetic fluid or it is a complex fluid like protein issues or hemorrhagic fluid. So if you see those 7 things which we discussed everything got covered what we routinely do in our reports so if you make a table out of it we can describe each of these lesion and assign a orads category. So orads one are very simple they are either physiological or they are either simple lesions like follicles hemorrhagic cyst less than 3 cm or confidant corpus luteal cyst less than 3 cm orads 2 is almost certainly benign and importantly if you see unilocular cyst with no wall enhancement directly go into orads 2 so this is one of the commonest big cyst you will see they are unilocular there is no solid component and there is no enhancement so this is orads 2 they may turn into cyst adenoma sometime but these are orads 2 lesions. Unilocular with endometriotic contents when you are confident it is endometriotic cyst which we will discuss in some lecture today but that pertinent T2 shading sign is present you know that it is blood products inside and it is endometriotic cyst it is straight away orads 2. Even with lipid content and no enhancing solid tissue so your dermoids when we said that it is either orads 2 or orads 4 so when it is simple lipid content and no enhancing solid tissue that is most important no enhancing solid tissue. So that is why you have to take subtracted images whenever you have T1 hyper intensity in your lesion pre contrast so fat component will be bright on T1 even post contrast if you take it may be just bright because of the fat content but they will do fat suppression if you want to see the enhancement in the solid component you should take up subtracted image so that is important enhancing solid component will make it orads 4 and lesion with homogenously T2 dark solid component this is something important if it is completely solid so that gives us an impression completely solid towards orads 5 but if it is homogenously T2 dark completely solid it is orads 2 fibromaticoma so you can leave it to that spectrum of orads 2 lesion so these few terms are important then dilated fallopian tubes hematosulpings hydro sulpings and parovarian simple cells again become orads 2 what is orads 3 unilocular but with some kind of proteinaceous hemorrhagic or mucinous fluid within it hemorrhagic fluid when you are sure it is not endometriotic cyst and it has enhancing walls so mainly the enhancing wall make it's orads 3 so that is one thing which is important then multilocular with smooth septal enhancement or wall enhancement making it orads 3 so very easy no enhancement orads 2 enhancing wall starts come towards orads 3 solid lesion not homogenously dark again and again they have put in not homogenously dark homogenously dark on T2 becomes fibromaticoma now this is not fibromaticoma we know that and it has a low intensity curve still orads 3 lesions like brenners few more examples like hematosulpings then coming to so we will quickly finish orads 4 lesion we will have everything a solid component enhancing septal enhancing wall and intermediate kind of curve so this is orads 4 lesion and dermoid with a squamous cell so that is when we have to coil of coil of fat containing lesion as orads 4 then it has a solid component which has enhancement and orads 5 will have lesion with solid tissue with high risk of intensity curve so this will become orads 5 highly malignant kind of a lesion and they have also given a calculator which is easily available they have questions in that calculator so even you don't have to put in much brains here just click yes no yes no and they will give you the orads score so I think we can start using this often if you have not yet started so just you have to choose whether they start with the most risky features that is the irregular thickening peritoneal thickening etc if you choose yes here it becomes directly orads 5 and then this table is there very explaining that what to do next so orads 3 4 5 they have to be managed histopathological diagnosis is required important orads 4 5 you would need a oncospecialist also in picture you will need to see the extent of the disease spread in orads 5 disorders and then there is no standardized guideline but most often in place pet scan also comes in picture when they want to see the complete extent as a index scan so I had kept few examples but I think time is less so just I am just putting that 7 pointers are there any lesion start describing using those 7 pointers like this lesion is a single unilocule you are seeing it's a thin wall but some T2 hypointense areas there that area is T1 completely homogenously dark and it is not showing any enhancement that whatever solid thing it is seen inside it's just the wall which is enhancing so it is not actual solid component which is there so it becomes just orads true so debris, fat, blood clots they are not solid component in your lesions so this is just orads 2 so that was Sira's study nomad this again is a multi-locular lesion multi-locular brings it to orads 3 category post contrast septal and wall enhancement again orads 3 category so you have to see the way it is picking up contrast if it is still dynamically low grade you keep it into orads 3 so this was orad 3 mu sinus study nomad again but it will require histopath it's his orads 3 so there are differences importantly between Sira's mu sinus and mu sinus again you can go through these but mu sinus most of the time are unilateral and multi-locular they will have some kind of proteinaceous content so if you see your T1 they will be heterogeneous in appearances they are less common as compared to Sira's varieties and Sira's are more into peritoneal spread and those kinds of tendency last case all the malignant features which we know are present in this and it fits into your orads 5 category it has diffusion restriction also so though orads are not talking about those particular ADC values but in the protocol they have suggested you doing diffusion with a higher B value so it has non-physiological solid lesion heterogeneous enhancement high pickup with peritoneal thickening it becomes orads 5 so with this whatever we have discussed this chart is also there are lot of you know guidelines of the ACR European society Korean society everybody has come up based on these orads and they are easily available and very easy to understand as well what we discussed in the last half an hour so to conclude MRI is the investigation of choice as we saw it can be a solve a problem solving tool it gives us the exact idea about the organ of origin and extent of the lesion orads if we try and use in our reports as we are using by rats our reporting will be easier time saving and standardized as well so thank you all for your patience listening